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Applications Will Be Processed When Submitted ProperlyCompleted.
<br /> APPLICATION
<br /> (For Non-Transferable; Revocable,'and Suspendable) SEPTAGE
<br /> ' ENVIRONMENTAL HEALTH-PERMIT
<br /> LIQUID WASTE
<br /> ,.
<br /> Appiication is hereby made to car n busingss i the Jun is tonal-prea of the•S J quip Local Distr t.
<br /> -': �� dress
<br /> ,rBusiness Name (DBA)� - - v• ^� � " '
<br /> rr_ �. 1 _ Address
<br /> Firm Partners, Addresses and one ,Numbers i
<br /> aBusiness Telephone No. Emergengy Telephone No.
<br /> Contractor Licence No.
<br /> a. �z f Title ate
<br /> L Applicants'Name (Pant} -
<br /> Please check Applicable Category(1-7)and Fill in the Required Information F 31s h
<br /> �t i.,-E]-.PUMPER VEHICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) W
<br />*� ` ' ` -J19--
<br /> F _ - Disposal Sites,
<br /> - --
<br /> ` or July 1, June 30, '--- p ]
<br /> Description(Make/Yr.,Color) CAL. License Renewal No.
<br /> Serial No. CRL. License No.!' _
<br /> Capacity^ —�'"� �"`-'"" Gal;Weights&-Measures•Nb.
<br /> Equipment Parking Address -
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19 4
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored -
<br /> 3. ❑ PERCOLATION TEST .
<br /> R.S. or R.C.E. No.
<br /> .R.S.or R.C.E. Name
<br /> I
<br /> Test ILocation ) Test DatOTime
<br /> 4, p SANITATION PERM T
<br /> l
<br /> .Job address/Location
<br /> k -- - Addrpss i
<br /> Owner ❑ PACKAGE PLANT
<br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING F1LD SEEPAGE PIT ❑ OTHER
<br /> -
<br /> t ❑"PERMANENT ❑ TEMPORARY lEW REPAIR -
<br /> 5. .I] CHEMICAL TOILETS For July 1„-June 30, 19
<br /> V
<br /> Type Construction; ( Disposal Site
<br /> Equipment Storage/Cleaning Location 6)
<br /> No. of Units
<br /> 6,,*E] PACKAGE TREATMENT PLANT For July,1, -June 30,19 , w ►
<br /> t Where Certified - t
<br /> Operator Name l t r
<br /> Rlan't Location _ -
<br /> � '- No.Units Served
<br /> Plant Capacity i i.
<br /> � } I.
<br /> 7. ❑ -LAUNDRY For�duly 1,-b une 30, 19, - ri t
<br /> �.q :e i I
<br /> SIZE: 1:1 Less Thian 1,000 Sq. Ft., \ ❑ More Than 1,000 Sq. '
<br /> ❑'DRY CLEANING Chemicals Used/Amount/Mo i I
<br /> * 1 E`r¢rt1 tt+atttitheper#ormenceattheworkforwhichtttispermitisissued,Istallnott�tllpioy ypersan
<br /> '�• Floren rnere�t?Icensed� ent 59I neh!reee.ti£a�*�+�fn30vw1 fY
<br /> iNi4,�,nT:r'�tar1�r� s',��_3 �,� .- .. �'- I ^^�•` t '� .tS'f�''far .. Cht 5'pp t t, s1 � �� ��
<br /> Ai Xtr1T3 s�sst�c'' r '� 1'fibt'£145 i af�
<br /> -
<br /> "x
<br /> Contractor's or :�:,-c�. - �. ��....,�- 8I :.;� � ¢ -� ,,114 •.ti,Wori<to'which this perinit is issued,I ha.it
<br /> 0fp91i r3pM)C W t'k4TTAl7 t 91R C,IP at IS Ol �i T I t
<br /> �f hereby certify t 1 havere ar Is a FP��I inn and that the work will be done In accordance with San Joaquin County
<br /> I ordinan es, aw d ru s nd a tS n #'th an Joaquin Local Health District.
<br /> P j
<br /> APPLICANT'S SIGNATURE'X s. I z `
<br /> i FOR DEPARTMENT USE ONLY
<br /> 2
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE' ❑ EACH, SD January 1 &Received By January 31 ❑ duly 1 &;Rece!v REMITuIy 3i
<br /> - -` .. '�
<br /> 81LLkING REMITTANCE• AMOUNT DUE-+- CHECKED
<br /> ' IBASE �, ,EXPLANATION {- .' REMITTED 'AMOUNT
<br /> - DATE. - ^ 'DATES
<br /> FEE s • �� h { TT
<br /> ^
<br /> { LESS 3 r z t
<br /> i PRORATION
<br /> { I
<br /> PLUS
<br /> PENALTY ;1
<br /> 3 OTHER
<br /> OTHER
<br /> IIssuance to * Mailed Delivered
<br /> Received-by Date Receipt No -*-, t Permit o. „yam {� .� -+ ,
<br /> •[ 1601 E:HAZELTON .,P-O.Box 2009 STOCKTON,CA 95201
<br /> 1 APPLICANT s RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES r
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